Care Coordinator
Company Description:
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.
We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Position Responsibilities:
Specific
- Conduct clinical review of prior authorization, concurrent review, and retrospective review requests to determine medical necessity and appropriateness of services.
- Collaborate with utilization management nurses and clinical staff to support timely decision-making.
- Review appeals and grievances related to medical necessity and participate in fair hearing processes as required.
- Ensure compliance with federal and state regulations, NCQA/URAC standards, and MCO policies.
- Serve as a liaison between the medical management department and providers, offering guidance on clinical criteria and utilization trends.
- Participate in interdisciplinary rounds and case review meetings as needed.
- Identify utilization trends and contribute to the development of policies, clinical criteria, and medical management strategies.
- Support quality improvement initiatives and population health programs as needed.
- Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance
- Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
- Deliver innovative, integrated solutions in support of client goals and engagements.
- Lead engagements ensuring completion of all contracted services
- Present findings, recommendations and plans to Client executives
- Facilitate complicated problem-solving discussions to drive to timely, effective decision making
- Advise and persuade key decision makers and influencers
- Deliver concise, clear interpersonal communication to both internal and external audiences
- Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s)
- Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
- Influence others to best course of action through advanced understanding of changing business landscapes
- Develop strategies, goals and plans in response to changing business conditions
- Leverage best practice methodologies and approaches across individual account strategies/ client plans.
- Establish short term KPIs and long-term goals and track progress to ensure achievement
- Develop or update policies, procedures and workflows as required to support business needs and requirements
- Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs
- Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities
- Support account management relationships with key client decision makers
Position Qualifications:
Competencies:- Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance
- Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes
- New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business
- New population strategy development including identification, program design and implementation
- Operationalizing requirements for complex memberships, ensuring outcome delivery
- Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity
- Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
- Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion
- Advanced knowledge of project management principles, methods, and techniques
- Ability to organize, prioritize, and manage multiple complex projects simultaneously
- Excellent communication skills both written and oral
- High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred
- Medical Degree (MD or DO) required;Must be actively licensed in Pennsylvania or New Jersey
- Masters degree in Healthcare or Business Administration or related field Degree preferred
- 10+ years administrative leadership achievement in health plan operations with progressive responsibility.
- CMO level experience preferred
- 7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc)
- 5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.
- Must be able to sit in a chair for extended periods of time
- Must be able to speak so that you are able to accurately express ideas by means of the spoken word
- Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
- Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
- Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
- Must be able to fluently communicate both verbally and in writing using the English language
- Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously
- Expected Hours of Work: Friday 8am – 5 pm; with ability to adjust to Client schedules as needed
- Travel: May be required, as needed by Client
- Direct Reports: None
- Salary Range: $100.00 - $150.00/ hr
Originally posted on